Unraveling the Mysteries of Biden vs. Trump on Health Care
We released one of our traditional “side by sides” today comparing President Biden and President Trump on health care. We have done this for every election cycle. This time, however, it was an especially tricky assignment.
Trump avoids policy and policy details, both as a personal characteristic and a way to duck accountability and media criticism. The directions he might take have to be deduced from remarks he has made here and there, positions he took when he was president, and most of all, from the policy positions conservative Republican organizations have taken. Many are led by folks who would take up posts in a second Trump administration. The tricky part is that we can’t know for sure if Trump will embrace the policy plans hatched by several conservative groups, if he is elected president. And Trump himself isn’t saying.
The “maybe I will, maybe I won’t” posture has become the official position of the Trump campaign. According to the Washington Post:
The Trump campaign has distanced itself from the extensive planning. Campaign managers Susie Wiles and Chris LaCivita said in a statement, “Unless a message is coming directly from President Trump or an authorized member of his campaign team, no aspect of future presidential staffing or policy announcements should be deemed official.”
(For this reason, unless Trump has endorsed a policy proposal, we have not included it in our side by side.
Biden has certainly articulated clearer policy positions and some specific policies, and has generally pressed the advantage he has with voters on health, but he is not running on big new plans for health care. Rather, he focuses on incremental policies that resonate with voters and distinguish him as the candidate who cares about health care, such as adding more drugs to the Medicare drug price negotiation list, extending the $35 cap on insulin copays and $2,000 cap on out-of-pocket costs from Medicare to private coverage, and continuing enhanced ACA subsidies which are set to expire.
What we are left with, then, is providing the best discernable analysis of the differences between the two candidates. Their differences tend to be articulated, covered by the press and digested by Congress policy by policy and program by program. That worm’s eye view is the most relevant to ongoing debate and that’s how we have analyzed the differences between Biden and Trump on health care in our side by side. From the bird’s eye view, however, the differences are bigger, amounting to a fork in the road in direction on the role of the federal government in health and federal health spending. Conservative Republicans envision, and will try to sell Trump on, an agenda that would dramatically dial back the federal role in health while expanding the role of states and market choices. Deep cuts in federal health spending would accompany these changes. By contrast (and also in contrast to the Medicare for All agenda of the progressive left), Biden will try to build incrementally on recent expansions in public programs: Medicaid, the ACA and Medicare. Biden’s approach is not small ball, nor is it sweeping health system reform; it’s an aggressive form of incrementalism.
Then there is abortion. The difference in direction on abortion and reproductive health is so stark and has been so widely discussed it does not need to be described again. However, how fully Trump would prosecute the conservative Republican agenda on abortion and reproductive health is at least something of an open question. Most recently, he has said abortion policy should be a matter left to the states.
Whether dramatic policy changes could be achieved is an entirely different matter that depends on who controls Congress, who is appointed to high positions, public opinion, positioning for the next midterm election, and much more. What follows are some of the key health policy flashpoints.
With Trump’s pledge not to cut Medicare, it’s likely that the main action to cut federal spending and reduce the federal role in health will focus on Medicaid and the ACA (stopping short of another effort at repeal). The Republican Study Committee has proposed a complex series of block grants, combining ACA subsidies and Medicaid coverage, that they estimate will reduce federal spending by $4.5 trillion dollars over ten years. A cut of that magnitude sounds fantastical and would decimate coverage for the more than 100 million lower income people who get it from Medicaid and the ACA now. It would certainly be pared back in legislative negotiations. Just as certainly, the implementation of any law of this kind would be delayed in a bargain for support from current Republican governors, so that federal funding cuts hit their states when they are out of office. Providers would strongly oppose the cuts, which would erode their reimbursement rates. A Medicaid/ACA coverage block grant like this could be the main drama in health policy following a Trump election. With Medicaid as far reaching and as popular as it is today, and the magnitude of the cuts contemplated, even with a Republican trifecta producing control of Congress and the White House, odds of passage are iffy. It might garner more support if Republicans decided to sacrifice their spending reduction goals for their ideological and policy objectives.
Trump’s squishy “no Medicare cuts” campaign pledge notwithstanding, it should not be assumed that Medicare is off the hook. The same Republican groups are again proposing converting Medicare to a premium support or voucher-like program. How such a program would affect beneficiaries and federal spending turns mightily on details and can be subject to argument and competing analysis. Is the voucher tied to the lowest cost plan or a better plan than that? How would the value of the voucher increase over time? Are the plan’s architects more interested in federal savings or the policy goal of further privatizing Medicare? Trump is famously averse to immersing himself in policy details and could choose to interpret a premium support plan in ways that he believes honor his campaign promises. Politically, however, Medicare is a health care issue in a league of its own. Midterms start to rear their heads quickly and Republicans will not want to hand democrats Medicare—or what they call MediScare—as a central issue.
In our candidate comparison, we describe the differences between Trump and Biden on abortion and reproductive health. There is a tension between the old New York Trump and the current MAGA Trump on abortion and reproductive health, and it’s impossible to say where a Trump no longer running for election would land when conservatives attempt to ram home more severe restrictions on abortion or contraception or any aspect of reproductive health. He certainly would not stonewall them, but he might not embrace 100% of their agenda either.
A tricky area in which to decipher differences is drug costs. Trump himself has never been a fan of the drug companies and took them on in his first term. He has promised to issue an executive order on drug prices he may or may not have the authority to issue. But Republicans would want to roll back the Biden regulatory measures to rein in some drug costs and certainly would not expand them. This area more than most underscores how challenging it is to analyze the positions of a presidential candidate who doesn’t take positions and may or may not follow the plans laid out for him by conservative groups whose members will populate his administration.
There are many other differences on other health and health-related issues, from gun violence to substance use to LBGTQ issues to global health, all covered in the side by side.
Should President Biden win re-election, you may also see a re-emergence of more expansive proposals from the left, including a re-emergence of Medicare for All proposals. The Democratic left has largely held its fire and supported Biden’s health policies while worried about the Trump threat.
The states also bear watching. Generally ideological purity fades to budgetary interest for governors when they learn how federal legislation will affect their state. But governors and legislatures have become even more partisan and ideological, and past patterns may no longer hold.
Typically, during an election campaign, large teams vying for jobs and working to satisfy constituency groups for campaigns prepare policy plans on virtually every health issue, posting them on a candidate’s website. Once elected, candidates can be expected to put most of those plans into the legislative process and to implement what they can administratively. This time, with a president running for re-election whose policies are already set, and a former president who shuns policy details, both camps are skipping over the usual policy planning process, and the routine job of describing the differences between the two candidates on health issues is a thousand-piece puzzle.